Behind a restricted mouth lies a restricted personality”- this is more or less true for the patients suffering from the highly perplexing disease called oral submucous fibrosis.
The higher predominance in areca nut usage by males may be due to the ease and places in which they can buy the product as compared to females. In addition females are more health conscious and chewing in females has a negative aesthetic value. Due to increase in availability of areca nut and pan masala sachets in multi-attractive packings with extensive publicity by the manufacturers also play a major role in targeting the younger population.
The most accepted etiological factor is the concept of chewing betel nut and tobacco in its various forms. Other predisposing factors such as autoimmunity, collagen disorders, genetic susceptibility and nutritional factors also play a vital role.
Medical management with local injections of corticosteroids and hyaluronidase, along with systemic ingestion of multivitamins, anti-oxidants apparently has been known to decrease the burning sensation. Local physiotherapy, in the form of hot rinses or selective deep heating therapies (such as short wave diathermy), does not produce any beneficial effects [5,9]. Use of intra-lesional g interferon, an antifibrotic cytokine, has been shown to reduce the burning sensation and to improve mouth-opening .
Steroids act by opposing the action of soluble factors released by sensitized lymphocytes following activation by specific antigens steroids, act as immunosuppressive agents. It also prevents or suppresses inflammatory reactions thereby preventing fibrosis by decreasing fibroblastic proliferation and deposition of collagen. The initial symptomatic relief could be due to the anti-inflammatory action of the steroids, which helps in clearing the juxta-epithelial inflammation .
Hyaluronidase causes breakage and dissolution of fibrous bands thus providing relief from the condition. By virtue of its specific action on hyaluronic acid, which plays an important role in the formation of collagen, hyaluronidase may be responsible for the better results in patients with restricted mouth opening .
Surgical management is indicated in moderately advanced to advanced cases of oral submucous fibrosis, as defined by maximum mouth-opening of 25 mm .
Simple division of fibrotic bands with secondary healing has resulted in more fibrosis and disability . Reconstruction of the resultant defect is problematic and various methods have been described including split thickness skin grafts, Buccal Fat Pad (BFP) grafts , microvascular free radial forearm flaps , tongue flap  and nasolabial flap . Additional procedures like masticatory muscle myotomy and bilateral coronoidectomy can be performed to enhance mouth opening.
Use of flaps has the following disadvantages :
- Time consuming
- Scarring at the graft host site
- Increased hospital stay
- Possibility of graft failure (in free flaps)
- Possible necessity of secondary procedures like debulking
All the above described methods of reconstruction are either prone to early recurrence of fibrosis or more importantly, in the setting of a pre-cancerous lesion, make regular monitoring of the affected mucosa for carcinomatous change difficult or even impossible .
Traditional methods of releasing the fibrotic bands with cold knife are associated with increased per-operative bleeding which is difficult to control in the presence of severe trismus. Moreover introduction of surgical instruments into the operative site is difficult.
Electro surgical techniques, though associated with reduced blood loss have the major disadvantage of deep tissue damage, which in turn leads to increased post operative fibrosis and thus negates the early gains achieved .
Among all the lasers available, of the numerous properties, penetration and absorption of rays are the two most relevant parameters for selection of diode laser in our study. Diode laser is a portable device which delivers rays through a fibre-optic cable and hence can be delivered to relatively “difficult-to-access” areas. Its cutting depth is less than 0.01 mm, and thus preserves tissues beyond this depth.
Diode laser offered several advantages over conventional surgical procedures like:
- The procedure done is a less time consuming technique with minimal morbidity
- Haemostatic nature of the surgery which allows surgery to be performed more precisely and accurately because of increased visibility and accessibility of the surgical site
- Decreased post operative pain and swelling
- Causes a reduction in bacterial counts thereby promoting quicker, more predictable healing with minimal post operative infection and inflammation
- Leads to healing with minimal scarring
Definite increase in mouth opening observed at post-op which eventually decreases over the next 3 months and later it stabilizes by around 6 month. This gradual decrease could be attributed to fibrosis of the tissue while healing.